Provider Demographics
NPI:1285687749
Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Other - Org Name:PROVIDENCE INFUSION AND PHARMACY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR REIMB REG STRAT/ASST SEC ENROLL
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:3333 S 120TH PL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98168-5134
Mailing Address - Country:US
Mailing Address - Phone:425-687-4400
Mailing Address - Fax:425-687-4401
Practice Address - Street 1:3333 S 120TH PL
Practice Address - Street 2:SUITE 10
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98168-5134
Practice Address - Country:US
Practice Address - Phone:425-687-4400
Practice Address - Fax:425-687-4401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
WAPHAR.CF.603896083336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1006822Medicaid
WA1006822Medicaid